A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.
What nursing interventions should be included in the plan of care? Select all that apply.

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

Choice A rationale

Limiting activity for a day or two after returning home is a correct understanding. After a thoracentesis, it’s recommended to limit activity for a day or two to allow the body to recover.

Choice B rationale

Anticipating a stinging feeling during needle insertion is a correct understanding. The patient will feel a stinging sensation when the local anesthetic is injected.

Choice C rationale

Preparing to sit forward with arms propped on a table is a correct understanding. This position helps to expand the space between the ribs, making it easier for the doctor to access the pleural space.

Choice D rationale

Expecting a persistent cough after the procedure indicates a need for additional education. While a mild cough immediately after the procedure is normal, a persistent cough could indicate a complication such as a pneumothorax.